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Lee C, Dennett AM, Pinson JA, Lewis AK. Caffeine consumed prior to cardiac stress testing may affect diagnostic accuracy of nuclear medicine myocardial imaging of myocardial ischemia: A systematic review and meta-analysis. J Med Imaging Radiat Sci 2024; 55:134-145. [PMID: 38233285 DOI: 10.1016/j.jmir.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Myocardial perfusion imaging (MPI) is a well-established, non-invasive imaging procedure for the diagnosis and evaluation of patients with known or suspected coronary artery disease. With the increasing use of pharmacologic stress agents in myocardial perfusion imaging, strict preparation, including caffeine abstinence, is required. The aim of this review was to determine the effect of caffeine consumed prior to nuclear cardiac stress testing on the diagnostic accuracy. METHODS Medline, Embase and CINAHL were searched from the earliest available time until August 2022. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies version 2. Data pertaining to diagnostic accuracy were analysed using meta-analysis where appropriate and overall certainty of evidence evaluated using the Grades of Research, Assessment, Development and Evaluation approach. RESULTS Six studies (307 participants) from a yield of 735 articles were identified. Meta-analysis of two studies found no difference in the left ventricular ejection fraction of patients pre and post caffeine consumption (MD -0.31 %, 95% CI -4.32% to 3.7%). Meta-analysis of three studies found there was uncertainty as to whether caffeine consumption affected reversibility (MD -2.16 segments 95% CI -4.61 to 0.28) and descriptive summary of three studies found mixed results for size of stress defects. CONCLUSION The low quality evidence synthesized in this systematic review suggests caffeine may affect the diagnostic accuracy in myocardial perfusion imaging for ischemia detection in patients with chest pain and intermediate-to-high risk of coronary artery disease.
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Affiliation(s)
- Christine Lee
- Department of Nuclear Medicine, Eastern Health, Box Hill Hospital, Box Hill, Melbourne, Australia.
| | - Amy M Dennett
- Eastern Health, Allied Health Clinical Research Office, Box Hill, Australia; School of Allied Health Human Services and Sport, La Trobe University, Bundoora Australia
| | - Jo-Anne Pinson
- Sir Peter MacCallum Department of Oncology, The Radiopharmaceutical Research Laboratory, The Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia; Medicinal Chemistry, Faculty of Pharmacy and Pharmaceutical Sciences, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Parkville, Australia
| | - Annie K Lewis
- Eastern Health, Allied Health Clinical Research Office, Box Hill, Australia; School of Allied Health Human Services and Sport, La Trobe University, Bundoora Australia
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2
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Mehta CR, Naeem A, Patel Y. Cardiac Computed Tomography Angiography in CAD Risk Stratification and Revascularization Planning. Diagnostics (Basel) 2023; 13:2902. [PMID: 37761268 PMCID: PMC10530183 DOI: 10.3390/diagnostics13182902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
PURPOSE OF REVIEW Functional stress testing is frequently used to assess for coronary artery disease (CAD) in symptomatic, stable patients with low to intermediate pretest probability. However, patients with highly vulnerable plaque may have preserved luminal patency and, consequently, a falsely negative stress test. Cardiac computed tomography angiography (CCTA) has emerged at the forefront of primary prevention screening and has excellent agency in ruling out obstructive CAD with high negative predictive value while simultaneously characterizing nonobstructive plaque for high-risk features, which invariably alters risk-stratification and pre-procedural decision making. RECENT FINDINGS We review the literature detailing the utility of CCTA in its ability to risk-stratify patients with CAD based on calcium scoring as well as high-risk phenotypic features and to qualify the functional significance of stenotic lesions. SUMMARY Calcium scores ≥ 100 should prompt consideration of statin and aspirin therapy. Spotty calcifications < 3 mm, increased non-calcified plaque > 4 mm3 per mm of the vessel wall, low attenuation < 30 HU soft plaque and necrotic core with a rim of higher attenuation < 130 HU, and a positive remodeling index ratio > 1.1 all confer additive risk for acute plaque rupture when present. Elevations in the perivascular fat attenuation index > -70.1 HU are a strong predictor of all-cause mortality and can further the risk stratification of patients in the setting of a non-to-minimal plaque burden. Lastly, a CT-derived fractional flow reserve (FFRCT) < 0.75 or values from 0.76 to 0.80 in conjunction with additional risk factors is suggestive of flow-limiting disease that would benefit from invasive testing. The wealth of information available through CCTA can allow clinicians to risk-stratify patients at elevated risk for an acute ischemic event and engage in advanced revascularization planning.
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Affiliation(s)
- Chirag R. Mehta
- Department of Cardiology, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA (Y.P.)
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3
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Patel P, Emrich T, Schoepf UJ, Mehta V, Bayer RR, von Assen M, Giovagnoli V, Jeudy J, Varga-Szemes A, White C. Comprehensive Computed Tomography Imaging of Vessel-specific and Lesion-specific Myocardial Ischemia. J Thorac Imaging 2023; 38:212-225. [PMID: 34029280 DOI: 10.1097/rti.0000000000000592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Coronary computed tomographic angiography (CCTA) has emerged as a fast and robust tool with high sensitivity and excellent negative predictive value for the evaluation of coronary artery disease, but is unable to estimate the hemodynamic significance of a lesion. Advances in computed tomography (CT)-based diagnostic techniques, for example, CT-derived fractional flow reserve and CT perfusion, have helped transform CCTA primarily from an anatomic assessment tool to a technique that is able to provide both anatomic and functional information for a stenosis. With the results of the ISCHEMIA trial published in 2019, these advanced techniques can elevate CCTA into the role of a better gatekeeper for decision-making and can help guide referral for invasive management. In this article, we review the principles, limitations, diagnostic performance, and clinical utility of these 2 functional CT-based techniques in the evaluation of vessel-specific and lesion-specific ischemia.
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Affiliation(s)
- Pratik Patel
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Tilman Emrich
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - U Joseph Schoepf
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Varun Mehta
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Richard R Bayer
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Marly von Assen
- Department of Radiology and Imaging Sciences, Division of Cardiothoracic Imaging, Emory University Hospital, Atlanta, GA
| | - Vincent Giovagnoli
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Jean Jeudy
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Akos Varga-Szemes
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Charles White
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
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4
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Groenhoff L, De Zan G, Costantini P, Siani A, Ostillio E, Carriero S, Muscogiuri G, Bergamaschi L, Patti G, Pizzi C, Sironi S, Pavon AG, Carriero A, Guglielmo M. The Non-Invasive Diagnosis of Chronic Coronary Syndrome: A Focus on Stress Computed Tomography Perfusion and Stress Cardiac Magnetic Resonance. J Clin Med 2023; 12:jcm12113793. [PMID: 37297986 DOI: 10.3390/jcm12113793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/22/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
Coronary artery disease is still a major cause of death and morbidity worldwide. In the setting of chronic coronary disease, demonstration of inducible ischemia is mandatory to address treatment. Consequently, scientific and technological efforts were made in response to the request for non-invasive diagnostic tools with better sensitivity and specificity. To date, clinicians have at their disposal a wide range of stress-imaging techniques. Among others, stress cardiac magnetic resonance (S-CMR) and computed tomography perfusion (CTP) techniques both demonstrated their diagnostic efficacy and prognostic value in clinical trials when compared to other non-invasive ischemia-assessing techniques and invasive fractional flow reserve measurement techniques. Standardized protocols for both S-CMR and CTP usually imply the administration of vasodilator agents to induce hyperemia and contrast agents to depict perfusion defects. However, both methods have their own limitations, meaning that optimizing their performance still requires a patient-tailored approach. This review focuses on the characteristics, drawbacks, and future perspectives of these two techniques.
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Affiliation(s)
- Léon Groenhoff
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Giulia De Zan
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, 28100 Novara, Italy
- Department of Cardiology, Division of Heart and Lungs, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
| | - Pietro Costantini
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Agnese Siani
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Eleonora Ostillio
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Serena Carriero
- Postgraduate School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Giuseppe Muscogiuri
- Department of Radiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, 20149 Milan, Italy
- School of Medicine, University of Milano-Bicocca, 20900 Monza, Italy
| | - Luca Bergamaschi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Carmine Pizzi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Sandro Sironi
- School of Medicine, University of Milano-Bicocca, 20900 Monza, Italy
- Department of Radiology, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Anna Giulia Pavon
- Cardiovascular Department, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
| | | | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
- Department of Cardiology, Haga Teaching Hospital, 2545 AA The Hague, The Netherlands
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5
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Leo I, Nakou E, Artico J, Androulakis E, Wong J, Moon JC, Indolfi C, Bucciarelli-Ducci C. Strengths and weaknesses of alternative noninvasive imaging approaches for microvascular ischemia. J Nucl Cardiol 2023; 30:227-238. [PMID: 35918590 DOI: 10.1007/s12350-022-03066-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/19/2022] [Indexed: 11/26/2022]
Abstract
Structural and functional abnormalities of coronary microvasculature are highly prevalent in several clinical settings and often associated with worse clinical outcomes. Therefore, there is a growing interest in the detection and treatment of this, often overlooked, disease. Coronary angiography allows the assessment of the Coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR). However, the measurement of these parameters is not always feasible because of limited technical availability and the need for a cardiac catheterization with a small but real risk of potential complications. Recent advances in non-invasive imaging techniques allow the assessment of coronary microvascular function with good accuracy and reproducibility. The objective of this review is to discuss the strengths and weaknesses of alternative non-invasive approaches used in the diagnosis of coronary microvascular dysfunction (CMD), highlighting the most recent advances for each imaging modality.
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Affiliation(s)
- Isabella Leo
- Royal Brompton and Harefield Hospitals, Guys's and St Thomas' NHS Foundation Trust, London, UK
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Eleni Nakou
- Royal Brompton and Harefield Hospitals, Guys's and St Thomas' NHS Foundation Trust, London, UK
| | - Jessica Artico
- Institute of Cardiovascular Science, University College London, Gower Street, London, UK
- St Bartholomew's Hospital, Barts Heart Centre, West Smithfield, London, UK
| | - Emmanouil Androulakis
- Royal Brompton and Harefield Hospitals, Guys's and St Thomas' NHS Foundation Trust, London, UK
| | - Joyce Wong
- Royal Brompton and Harefield Hospitals, Guys's and St Thomas' NHS Foundation Trust, London, UK
| | - James C Moon
- Institute of Cardiovascular Science, University College London, Gower Street, London, UK
- St Bartholomew's Hospital, Barts Heart Centre, West Smithfield, London, UK
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Chiara Bucciarelli-Ducci
- Royal Brompton and Harefield Hospitals, Guys's and St Thomas' NHS Foundation Trust, London, UK.
- Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College University, London, UK.
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6
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Canan A, Barbosa MF, Nomura CH, Abbara S, Kay FU. Cardiac CT Perfusion Imaging. CURRENT RADIOLOGY REPORTS 2022. [DOI: 10.1007/s40134-022-00406-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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7
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Litmanovich D, Hurwitz Koweek LM, Ghoshhajra BB, Agarwal PP, Bourque JM, Brown RKJ, Davis AM, Fuss C, Johri AM, Kligerman SJ, Malik SB, Maroules CD, Meyersohn NM, Vasu S, Villines TC, Abbara S. ACR Appropriateness Criteria® Chronic Chest Pain-High Probability of Coronary Artery Disease: 2021 Update. J Am Coll Radiol 2022; 19:S1-S18. [PMID: 35550795 DOI: 10.1016/j.jacr.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
Abstract
Management of patients with chronic chest pain in the setting of high probability of coronary artery disease (CAD) relies heavily on imaging for determining or excluding presence and severity of myocardial ischemia, hibernation, scarring, and/or the presence, site, and severity of obstructive coronary lesions, as well as course of management and long-term prognosis. In patients with no known ischemic heart disease, imaging is valuable in determining and documenting the presence, extent, and severity of obstructive coronary narrowing and presence of myocardial ischemia. In patients with known ischemic heart disease, imaging findings are important in determining the management of patients with chronic myocardial ischemia and can serve as a decision-making tool for medical therapy, angioplasty, stenting, or surgery. This document summarizes the recent growing body of evidence on various imaging tests and makes recommendations for imaging based on the available data and expert opinion. This document is focused on epicardial CAD and does not discuss the microvascular disease as the cause for CAD. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Diana Litmanovich
- Harvard Medical School, Boston, Massachusetts; and Chief, Cardiothoracic imaging Section, Beth Israel Deaconess Medical Center.
| | - Lynne M Hurwitz Koweek
- Panel Chair, Duke University Medical Center, Durham, North Carolina; Panel Chair ACR AUG committee
| | - Brian B Ghoshhajra
- Panel Vice-Chair, Division Chief, Cardiovascular Imaging, Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Prachi P Agarwal
- Division Director of Cardiothoracic Radiology and Co-Director of Congenital Cardiovascular MR Imaging, University of Michigan, Ann Arbor, Michigan
| | - Jamieson M Bourque
- Medical Director of Nuclear Cardiology and the Stress Laboratory, University of Virginia Health System, Charlottesville, Virginia; Nuclear cardiology expert
| | - Richard K J Brown
- University of Michigan Health System, Ann Arbor, Michigan; and Vice Chair of Clinical Operations, Department of Radiology and Imaging Sciences, University of Utah
| | - Andrew M Davis
- The University of Chicago Medical Center, Chicago, Illinois; American College of Physicians; and Associate Vice-Chair for Quality, Department of Medicine, University of Chicago
| | - Cristina Fuss
- Oregon Health & Science University, Portland, Oregon; SCCT Member of the Board; Section Chief Cardiothoracic Imaging Department of Diagnostic Radiology, Oregon Health & Science University; ABR OLA Cardiac Committee; and NASCI Program Vice-Chair
| | - Amer M Johri
- Queen's University, Kingston, Ontario, Canada; Cardiology Expert; and ASE Board Member
| | | | - Sachin B Malik
- Division Chief Thoracic and Cardiovascular Imaging, Director of Cardiac MRI, Director of MRI, VA Palo Alto Health Care System, Palo Alto, California and Stanford University, Stanford, California
| | | | - Nandini M Meyersohn
- Fellowship Program Director, Massachusetts General Hospital, Boston, Massachusetts
| | - Sujethra Vasu
- Director, Cardiac MRI and Cardiac CT, Wake Forest University Health Sciences, Winston Salem, North Carolina; Society for Cardiovascular Magnetic Resonance
| | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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8
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Pontone G, Rossi A, Guglielmo M, Dweck MR, Gaemperli O, Nieman K, Pugliese F, Maurovich-Horvat P, Gimelli A, Cosyns B, Achenbach S. Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part II. Eur Heart J Cardiovasc Imaging 2022; 23:e136-e161. [PMID: 35175348 PMCID: PMC8944330 DOI: 10.1093/ehjci/jeab292] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/28/2021] [Indexed: 11/12/2022] Open
Abstract
Cardiac computed tomography (CT) was initially developed as a non-invasive diagnostic tool to detect and quantify coronary stenosis. Thanks to the rapid technological development, cardiac CT has become a comprehensive imaging modality which offers anatomical and functional information to guide patient management. This is the second of two complementary documents endorsed by the European Association of Cardiovascular Imaging aiming to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. In this article, emerging CT technologies and biomarkers, such as CT-derived fractional flow reserve, perfusion imaging, and pericoronary adipose tissue attenuation, are described. In addition, the role of cardiac CT in the evaluation of atherosclerotic plaque, cardiomyopathies, structural heart disease, and congenital heart disease is revised.
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Affiliation(s)
- Gianluca Pontone
- Corresponding author. Tel: +39 02 58002574; Fax: +39 02 58002231. E-mail:
| | | | - Marco Guglielmo
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marc R Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francesca Pugliese
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Alessia Gimelli
- Fondazione CNR/Regione Toscana “Gabriele Monasterio”, Pisa, Italy
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair ziekenhuis Brussel, Brussel, Belgium
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University of Erlangen, Erlangen, Germany
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9
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Azhar AZ, Rai D, Bandyopadhyay D, Rzechorzek W, Akhtar T, Aronow WS, Ranjan P. Use of coronary artery calcium and coronary tomography angiography in the evaluation of ischemic heart disease. Hosp Pract (1995) 2022; 50:9-16. [PMID: 35037541 DOI: 10.1080/21548331.2022.2030630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Over the years, significant technological advances have been made in the field of cardiac CT imaging which has led to the widespread use of the modality in the evaluation of ischemic and structural heart disease. The advent of newer scanning techniques has led to a reduction in scanning time as well as a reduction in the radiation and contrast media dose required - making these scans both convenient and safer to perform. Research has shown that coronary CT angiography has a high negative predictive value in the evaluation of patients with coronary artery disease. There is more recent evidence that coronary CTA has a positive impact on clinical outcomes as well. In this review article, we discuss the clinical applications of coronary CTA in the evaluation of patients with stable ischemic heart disease, the most recent studies evaluating the efficacy and limitations of the modality, the role of coronary calcium in cardiovascular risk prediction in asymptomatic patients and the future applications of the modality.
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Affiliation(s)
| | - Devesh Rai
- Department of Cardiology, Rochester General Hospital, Rochester, NY, USA
| | | | - Wojciech Rzechorzek
- Department of Cardiology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Tauseef Akhtar
- Medicine, John's Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Pragya Ranjan
- Department of Cardiology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
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10
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van Assen M, Duguay TM, Litwin SE, Bayer RR, Nance JW, Suranyi P, De Cecco CN, Varga-Szemes A, Jacobs BE, Johnson AA, Tesche C, Schoepf UJ. The Feasibility, Tolerability, Safety, and Accuracy of Low-radiation Dynamic Computed Tomography Myocardial Perfusion Imaging With Regadenoson Compared With Single-photon Emission Computed Tomography. J Thorac Imaging 2021; 36:345-352. [PMID: 32205821 DOI: 10.1097/rti.0000000000000502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Computed tomography (CT) myocardial perfusion imaging (CT-MPI) with hyperemia induced by regadenoson was evaluated for the detection of myocardial ischemia, safety, relative radiation exposure, and patient experience compared with single-photon emission computed tomography (SPECT) imaging. MATERIALS AND METHODS Twenty-four patients (66.5 y, 29% male) who had undergone clinically indicated SPECT imaging and provided written informed consent were included in this phase II, IRB-approved, and FDA-approved clinical trial. All patients underwent coronary CT angiography and CT-MPI with hyperemia induced by the intravenous administration of regadenoson (0.4 mg/5 mL). Patient experience and findings on CT-MPI images were compared to SPECT imaging. RESULTS Patient experience and safety were similar between CT-MPI and SPECT procedures and no serious adverse events due to the administration of regadenoson occurred. SPECT resulted in a higher number of mild adverse events than CT-MPI. Patient radiation exposure was similar during the combined coronary computed tomography angiography and CT-MPI (4.4 [2.7] mSv) and SPECT imaging (5.6 [1.7] mSv) (P-value 0.401) procedures. Using SPECT as the reference standard, CT-MPI analysis showed a sensitivity of 58.3% (95% confidence interval [CI]: 27.7-84.8), a specificity of 100% (95% CI: 73.5-100), and an accuracy of 79.1% (95% CI: 57.9-92.87). Low apparent sensitivity occurred when the SPECT defects were small and highly suspicious for artifacts. CONCLUSIONS This study demonstrated that CT-MPI is safe, well tolerated, and can be performed with comparable radiation exposure to SPECT. CT-MPI has the benefit of providing both complete anatomic coronary evaluation and assessment of myocardial perfusion.
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Affiliation(s)
- Marly van Assen
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Radiology, Center for Medical Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | - Taylor M Duguay
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Sheldon E Litwin
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Medicine, Medical University of South Carolina, Division of Cardiology, Charleston, SC
| | - Richard R Bayer
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Medicine, Medical University of South Carolina, Division of Cardiology, Charleston, SC
| | - John W Nance
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Pal Suranyi
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Medicine, Medical University of South Carolina, Division of Cardiology, Charleston, SC
| | - Carlo N De Cecco
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Akos Varga-Szemes
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Brian E Jacobs
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Addison A Johnson
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Christian Tesche
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany
| | - U Joseph Schoepf
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Medicine, Medical University of South Carolina, Division of Cardiology, Charleston, SC
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11
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Vattay B, Boussoussou M, Borzsák S, Vecsey-Nagy M, Simon J, Kolossváry M, Merkely B, Szilveszter B. Myocardial perfusion imaging using computed tomography: Current status, clinical value and prognostic implications. IMAGING 2021. [DOI: 10.1556/1647.2020.00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
AbstractCombined anatomical and functional evaluation of coronary artery disease (CAD) using computed tomography (CT) has recently emerged as an accurate, robust, and non-invasive tool for the evaluation of ischemic heart disease. Cardiac CT has become a one-stop-shop imaging modality that allows the simultaneous depiction, characterization, and quantification of coronary atherosclerosis and the assessment of myocardial ischemia. Advancements in scanner technology (improvements in spatial and temporal resolution, dual-energy imaging, wide detector panels) and the implementation of iterative reconstruction algorithms enables the detection of myocardial ischemia in both qualitative and quantitative fashion using low-dose scanning protocols. The addition of CT perfusion (CTP) to standard coronary CT angiography is a reliable tool to improve diagnostic accuracy. CTP using static first-pass imaging enables qualitative assessment of the myocardial tissue, whereas dynamic perfusion imaging can also provide quantitative information on myocardial blood flow. Myocardial tissue assessment by CTP holds the potential to refine risk in stable chest pain or microvascular dysfunction. CTP can aid the detection of residual ischemia after coronary intervention. Comprehensive evaluation of CAD using CTP might therefore improve the selection of patients for aggressive secondary prevention therapy or coronary revascularization with high diagnostic certainty. In addition, prognostic information provided by perfusion CT imaging could improve patient outcomes by quantifying the ischemic burden of the left ventricle. The current review focuses on the clinical value of myocardial perfusion imaging by CT, current status of CTP imaging and the use of myocardial CTP in various patient populations for the diagnosis of ischemic heart disease.
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Affiliation(s)
- Borbála Vattay
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Melinda Boussoussou
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Sarolta Borzsák
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Milán Vecsey-Nagy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Judit Simon
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Márton Kolossváry
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Ha S, Jung S, Park HB, Shin S, Arsanjani R, Hong Y, Lee BK, Jang Y, Jeon B, Park SI, Shim H, Chang HJ. Assessment of Image Quality for Selective Intracoronary Contrast-Injected CT Angiography in a Hybrid Angio-CT System: A Feasibility Study in Swine. Yonsei Med J 2021; 62:200-208. [PMID: 33635009 PMCID: PMC7934100 DOI: 10.3349/ymj.2021.62.3.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 12/03/2020] [Accepted: 12/14/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To compare image quality in selective intracoronary contrast-injected computed tomography angiography (Selective-CTA) with that in conventional intravenous contrast-injected CTA (IV-CTA). MATERIALS AND METHODS Six pigs (35 to 40 kg) underwent both IV-CTA using an intravenous injection (60 mL) and Selective-CTA using an intracoronary injection (20 mL) through a guide-wire during/after percutaneous coronary intervention. Images of the common coronary artery were acquired. Scans were performed using a combined machine comprising an invasive coronary angiography suite and a 320-channel multi-slice CT scanner. Quantitative image quality parameters of CT attenuation, image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), mean lumen diameter (MLD), and mean lumen area (MLA) were measured and compared. Qualitative analysis was performed using intraclass correlation coefficient (ICC), which was calculated for analysis of interobserver agreement. RESULTS Quantitative image quality, determined by assessing the uniformity of CT attenuation (399.06 vs. 330.21, p<0.001), image noise (24.93 vs. 18.43, p<0.001), SNR (16.43 vs. 18.52, p=0.005), and CNR (11.56 vs. 13.46, p=0.002), differed significantly between IV-CTA and Selective-CTA. MLD and MLA showed no significant difference overall (2.38 vs. 2.44, p=0.068, 4.72 vs. 4.95, p=0.078). The density of contrast agent was significantly lower for selective-CTA (13.13 mg/mL) than for IV-CTA (400 mg/mL). Agreement between observers was acceptable (ICC=0.79±0.08). CONCLUSION Our feasibility study in swine showed that compared to IV-CTA, Selective-CTA provides better image quality and requires less iodine contrast medium.
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Affiliation(s)
- Seongmin Ha
- Graduate School of Biomedical Engineering, Yonsei University College of Medicine, Seoul, Korea
- CONNECT-AI R&D Center, Yonsei University College of Medicine, Seoul, Korea
| | - Sunghee Jung
- CONNECT-AI R&D Center, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul, Korea
| | - Hyung Bok Park
- Division of Cardiology, Cardiovascular Center, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Sanghoon Shin
- Division of Cardiology, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Reza Arsanjani
- Cardiovascular Center, Mayo Clinic Scottsdale, Scottsdale, Arizona, USA
| | - Youngtaek Hong
- CONNECT-AI R&D Center, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Kwon Lee
- Division of Cardiology, Department of Internal Medicine, Heart Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yeonggul Jang
- CONNECT-AI R&D Center, Yonsei University College of Medicine, Seoul, Korea
| | - Byunghwan Jeon
- CONNECT-AI R&D Center, Yonsei University College of Medicine, Seoul, Korea
| | - Se Il Park
- Cardiovascular Product Evaluation Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hackjoon Shim
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Jae Chang
- CONNECT-AI R&D Center, Yonsei University College of Medicine, Seoul, Korea
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea.
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Seitun S, Clemente A, De Lorenzi C, Benenati S, Chiappino D, Mantini C, Sakellarios AI, Cademartiri F, Bezante GP, Porto I. Cardiac CT perfusion and FFR CTA: pathophysiological features in ischemic heart disease. Cardiovasc Diagn Ther 2020; 10:1954-1978. [PMID: 33381437 PMCID: PMC7758766 DOI: 10.21037/cdt-20-414] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 01/24/2023]
Abstract
Cardiac computed tomography (CCT) has rapidly evolved, becoming a powerful integrated tool for the evaluation of coronary artery disease (CAD), and being superior to other noninvasive methods due to its high accuracy and ability to simultaneously assess both lumen stenosis and atherosclerotic plaque burden. Furthermore, CCT is regarded as an effective gatekeeper for coronary angiography, and carries independent important prognostic information. In the last decade, the introduction of new functional CCT applications, namely CCT perfusion (CCTP) imaging and CT-derived fractional flow reserve (FFRCTA), has opened the door for accurate assessment of the haemodynamic significance of stenoses. These new CCT technologies, thus, share the unique advantage of assessing both myocardial ischemia and patient-specific coronary artery anatomy, providing an integrated anatomical/functional analysis. In the present review, starting from the pathophysiology of myocardial ischemia, we evaluate the existing evidence for functional CCT imaging and its value in relation to alternative, well-established, non-invasive imaging modalities and invasive indices of ischemia (currently the gold-standard). The knowledge of clinical applications, benefits, and limitations of these new CCT technologies will allow efficient and optimal use in clinical practice in the near future.
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Affiliation(s)
- Sara Seitun
- Department of Radiology, IRCCS Policlinico San Martino Hospital, Genoa, Italy
| | - Alberto Clemente
- Department of Radiology, CNR (National Council of Research)/Tuscany Region ‘Gabriele Monasterio’ Foundation (FTGM), Massa, Italy
| | - Cecilia De Lorenzi
- Department of Radiology, IRCCS Policlinico San Martino Hospital, Genoa, Italy
| | - Stefano Benenati
- Clinic of Cardiovascular Diseases, IRCCS Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
| | - Dante Chiappino
- Department of Radiology, CNR (National Council of Research)/Tuscany Region ‘Gabriele Monasterio’ Foundation (FTGM), Massa, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Science, Institute of Radiology, “G. d’Annunzio” University, Chieti, Italy
| | - Antonis I. Sakellarios
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina, Greece
| | | | - Gian Paolo Bezante
- Clinic of Cardiovascular Diseases, IRCCS Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
| | - Italo Porto
- Clinic of Cardiovascular Diseases, IRCCS Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
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Omarov YA, Sukhinina TS, Veselova TN, Shakhnovich RM, Zhukova NS, Merkulova IN, Pevzner DV, Ternovoy SK, Staroverov II. [Possibilities of Stress Computed Tomography Myocardial Perfusion Imaging in the Diagnosis of Ischemic Heart Disease]. ACTA ACUST UNITED AC 2020; 60:122-131. [PMID: 33228515 DOI: 10.18087/cardio.2020.10.n1028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/17/2020] [Indexed: 11/18/2022]
Abstract
Computed tomography angiography (CT-angiography, CTA) allows noninvasive visualization of coronary arteries (CA). This method is highly sensitive in detecting coronary atherosclerosis. However, standard CTA does not allow evaluation of the hemodynamic significance of found CA stenoses, which requires additional functional tests for detection of myocardial ischemia. This review focuses on possibilities of clinical use, limitations, technical aspects, and prospects of a combination of CT-angiography and CT myocardial perfusion imaging in diagnostics of ischemic heart disease.
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Affiliation(s)
- Y A Omarov
- National Medical Research Center of Cardiology" of the Ministry of Health of Russia, Moscow
| | - T S Sukhinina
- National Medical Research Center of Cardiology" of the Ministry of Health of Russia, Moscow
| | - T N Veselova
- National Medical Research Center of Cardiology" of the Ministry of Health of Russia, Moscow
| | - R M Shakhnovich
- National Medical Research Center of Cardiology" of the Ministry of Health of Russia, Moscow
| | - N S Zhukova
- National Medical Research Center of Cardiology" of the Ministry of Health of Russia, Moscow
| | - I N Merkulova
- National Medical Research Center of Cardiology" of the Ministry of Health of Russia, Moscow
| | - D V Pevzner
- National Medical Research Center of Cardiology" of the Ministry of Health of Russia, Moscow
| | - S K Ternovoy
- National Medical Research Center of Cardiology" of the Ministry of Health of Russia, Moscow; First Moscow State Medical University, Sechenov Moscow State Medical University (Sechenov University), Moscow
| | - I I Staroverov
- National Medical Research Center of Cardiology" of the Ministry of Health of Russia, Moscow
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15
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Kang EJ. Clinical Applications of Wide-Detector CT Scanners for Cardiothoracic Imaging: An Update. Korean J Radiol 2020; 20:1583-1596. [PMID: 31854147 PMCID: PMC6923215 DOI: 10.3348/kjr.2019.0327] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/23/2019] [Indexed: 12/21/2022] Open
Abstract
Technical developments in multidetector computed tomography (CT) have increased the number of detector rows on the z-axis, and 16-cm wide-area-coverage CT scanners have enabled volumetric scanning of the entire heart. Beyond coronary arterial imaging, such innovations offer several advantages during clinical imaging in the cardiothoracic area. The wide-detector CT scanner markedly reduces the image acquisition time to less than 1 second for coronary CT angiography, thereby decreasing the volume of contrast material and radiation dose required for the examination. It also eliminates stair-step artifacts, allowing robust improvements in myocardial function and perfusion imaging. Additionally, new imaging techniques for the cardiothoracic area, including subtraction imaging and free-breathing scans, have been developed and further improved by using the wide-detector CT scanner. This article investigates the technical developments in wide-detector CT scanners, summarizes their clinical applications in the cardiothoracic area, and provides a review of the recent literature.
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Affiliation(s)
- Eun Ju Kang
- Department of Radiology, College of Medicine, Dong-A University, Busan, Korea.
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Assen MV, Vonder M, Pelgrim GJ, Von Knebel Doeberitz PL, Vliegenthart R. Computed tomography for myocardial characterization in ischemic heart disease: a state-of-the-art review. Eur Radiol Exp 2020; 4:36. [PMID: 32548777 PMCID: PMC7297926 DOI: 10.1186/s41747-020-00158-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 03/30/2020] [Indexed: 12/21/2022] Open
Abstract
This review provides an overview of the currently available computed tomography (CT) techniques for myocardial tissue characterization in ischemic heart disease, including CT perfusion and late iodine enhancement. CT myocardial perfusion imaging can be performed with static and dynamic protocols for the detection of ischemia and infarction using either single- or dual-energy CT modes. Late iodine enhancement may be used for the analysis of myocardial infarction. The accuracy of these CT techniques is highly dependent on the imaging protocol, including acquisition timing and contrast administration. Additionally, the options for qualitative and quantitative analysis and the accuracy of each technique are discussed.
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Affiliation(s)
- M van Assen
- University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 EZ, Groningen, The Netherlands.
| | - M Vonder
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - G J Pelgrim
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - P L Von Knebel Doeberitz
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - R Vliegenthart
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Society of cardiovascular computed tomography expert consensus document on myocardial computed tomography perfusion imaging. J Cardiovasc Comput Tomogr 2020; 14:87-100. [DOI: 10.1016/j.jcct.2019.10.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/15/2019] [Indexed: 01/06/2023]
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18
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François CJ. "One-Stop Shop" For Evaluating Epicardial and Microvascular Coronary Artery Disease with Coronary CT Angiography and CT Myocardial Perfusion. Radiology 2019; 294:74-75. [PMID: 31747345 DOI: 10.1148/radiol.2019192363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Christopher J François
- From the Department of Radiology, Cardiovascular and Thoracic Imaging Sections, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792
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Magalhães TA, Cury RC, Cerci RJ, Parga Filho JR, Gottlieb I, Nacif MS, Pinto IM, Rochitte CE, Vilas-Boas F, Schvartzman PR. Evaluation of Myocardial Perfusion by Computed Tomography - Principles, Technical Background and Recommendations. Arq Bras Cardiol 2019; 113:758-767. [PMID: 31691758 PMCID: PMC7020871 DOI: 10.5935/abc.20190217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/20/2019] [Indexed: 11/20/2022] Open
Abstract
Coronary computed tomography angiography (CCTA) has gained a prominent role in the evaluation of coronary artery disease. However, its anatomical nature does not allow the evaluation of the functional repercussion of coronary obstructions. It has been made possible to evaluate Myocardial computed tomography perfusion (Myocardial CTP) recently, based on myocardial contrast changes related to coronary stenoses. Several studies have validated this technique against the anatomical reference method (cardiac catheterization) and other functional methods, including myocardial perfusion scintigraphy and fractional flow reserve. The Myocardial CTP is performed in conjunction with the CCTA, a combined analysis of anatomy and function. The stress phase (with assessment of myocardial perfusion) can be performed before or after the resting phase (assessment of resting perfusion and coronary arteries), and different acquisition parameters are proposed according to the protocol and type of equipment used. Stressors used are based on coronary vasodilation (e.g. dipyridamole, adenosine). Image interpretation, similar to other perfusion assessment methods, is based on the identification and quantification of myocardial perfusion defects. The integration of both perfusion and anatomical findings is fundamental for the examination interpretation algorithm, allowing to define if the stenoses identified are hemodynamically significant and may be related to myocardial ischemia.
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Affiliation(s)
- Tiago Augusto Magalhães
- Universidade Federal do Paraná - Complexo Hospital de Clínicas (CHC) -Universidade Federal do Paraná, Curitiba, PR - Brazil.,Hospital do Coração (HCor) - Division of cardiovascular CT/MR, São Paulo, SP - Brazil
| | | | | | - José Rodrigues Parga Filho
- Instituto do Coração (InCor) - Universidade de São Paulo - Division of Cardiovascular CT/MR, São Paulo, SP - Brazil
| | - Ilan Gottlieb
- Casa de Saúde São José - Division of Radiology, Rio de Janeiro, RJ - Brazil
| | - Marcelo Souto Nacif
- Complexo Hospitalar de Niterói - Division of Radiology, Niterói, RJ - Brazil.,Hospital Universitário Antônio Pedro, Niterói, RJ - Brazil
| | | | - Carlos Eduardo Rochitte
- Instituto do Coração (InCor) - Universidade de São Paulo - Division of Cardiovascular CT/MR, São Paulo, SP - Brazil
| | | | - Paulo R Schvartzman
- Hospital Moinhos de Vento - Division of Cardiovascular CT/MR, Porto Alegre, RS - Brazil
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Patel N, Li D, Nakanishi R, Fatima B, Andreini D, Pontone G, Conte E, O'Rourke R, Jayawardena E, Hamilton-Craig C, Nimmagadda M, Budoff MJ. Comparison of Whole Heart Computed Tomography Scanners for Image Quality Lower Radiation Dosing in Coronary Computed Tomography Angiography: The CONVERGE Registry. Acad Radiol 2019; 26:1443-1449. [PMID: 30683612 DOI: 10.1016/j.acra.2019.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/31/2018] [Accepted: 01/02/2019] [Indexed: 11/30/2022]
Abstract
RATIONALE AND OBJECTIVES Novel technology in coronary computed tomographic angiography allows assessment of coronary artery disease with high image quality (IQ). There are currently two wide detector "whole heart" coverage scanners available, which avoid misregistration artifacts. However, there are no data directly comparing IQ between the two scanners. The aim of the current study is to investigate if IQ is different between the most scanners of GE and Toshiba broad detector scanners. MATERIALS AND METHODS Prospective, observational, multicenter international cohort study comparing 236 consecutive patients who underwent coronary computed tomographic angiography using whole-heart scanners; 126 patients on scanner S1 ( Aquilion ONE Vision, Toshiba), and 110 patients on scanner S2 (Revolution CT, GE Healthcare). Hounsfield units were measured using regions of interest in the descending aorta at 6 points (cranial slice, level of the visualized first, second, third, and fourth spines, and the caudal slice). We also compared the coverage length (z-axis) of the full width field of view between a single rotation of the two scanners. RESULTS Evaluating mean CT attenuation values Hounsfield units through the scan range, are progressively reduced across the descending aorta in the S1 group, resulting in the larger difference of contrast brightness between the cranial and caudal slices compared to the S2 group (absolute difference: S2 13.0 ± 4.4 vs S1 141.9 ± 16.4, p < 0.0001; Percent difference: 19.3 ± 2.1 vs -3.4 ± 1.2, <0.0001). The standard deviation (SD) is similar at the cranial slice between the two scanners, however, the S1 group demonstrated higher SD-differential from cranial to caudal than S2 group. Median radiation exposure was significantly lower for the S2 scanner 1.50 ± 0.75 mSv vs the S1 system 1.9 mSv (IQR 1.7-2.7 mSv) (p = 0.01). Z-axis coverage was larger for the S2 scanner 152.5 mm (244 slices × 0.625 mm/slice) than 133 mm for S1 (266 slices × 0.5 mm/slice). CONCLUSION Although both "volume" scanners cover the whole heart z-axis with one beat, scans using the S1 scanner have a larger variability in attenuation values throughout the scan range, resulting in 20% increase in nonuniformity from cranial to caudal slice. Additionally, SD variation across the field of view, a metric of noise, is larger when using the S1 scanner vs the S2 scanner. These results indicate that the GE Revolution CT has more uniform contrast enhancement and more coverage, lower radiation and lower image noise compared to the Toshiba Aquilion ONE Vision system.
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Affiliation(s)
- Nirali Patel
- Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, CA
| | - Dong Li
- Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, CA
| | - Rine Nakanishi
- Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, CA; Department of Cardiovascular Medicine, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Badiha Fatima
- Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, CA
| | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Italy
| | | | | | - Rachael O'Rourke
- Department of Medical Imaging, The Prince Charles Hospital, Brisbane, Queensland Australia; University of Queensland, Brisbane, Queensland, Australia
| | - Eranthi Jayawardena
- Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, CA
| | - Christian Hamilton-Craig
- Department of Medical Imaging, The Prince Charles Hospital, Brisbane, Queensland Australia; University of Queensland, Brisbane, Queensland, Australia
| | - Manojna Nimmagadda
- Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, CA
| | - Matthew J Budoff
- Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, CA.
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Stress Computed Tomography Perfusion Versus Fractional Flow Reserve CT Derived in Suspected Coronary Artery Disease. JACC Cardiovasc Imaging 2019; 12:1487-1497. [DOI: 10.1016/j.jcmg.2018.08.023] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 11/23/2022]
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Liu J, Tian L, Wang S, Luo Z. Study of Hepatic Vascular Dynamics Based on Symmetrical Pulsating Perfusion. Ann Transplant 2019; 24:214-222. [PMID: 31000689 PMCID: PMC6486798 DOI: 10.12659/aot.913008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background The traditionally used perfusion method is constant flow. This study proposes a novel method called Symmetric Pulsating Flow (SPF) and verified that this method is applicable. Material/Methods The fluid dynamic behavior of perfusate in the vessel, the shear stress, and the vascular deformation were simulated based on the bi-directional fluid-structure interaction. The differences of the fluid dynamic behaviors and the mechanical characteristics of vascular wall were studied and compared between the 2 methods during the process of hepatic perfusion. The simulations and comparisons were carried out on 3 different vascular models. Results Utilizing the constant flow perfusion, a double vortex clearly appeared at the rear end of the foreign matter and reflux retention can be caused by the double vortex. The reflux retention caused lower shear stress against the vascular wall and thus brought new accumulation of foreign matter. The SPF perfusion, however, prevented the double vortex, and avoided such reflux retention during the vascular perfusion. In addition, the SPF can clean the vascular wall better with a slower speed, which causes less injury to the vessel, and the pulsating effect can reduce the accumulation of new foreign matter. Conclusions The SPF perfusion can clean the vascular wall more thoroughly with less injury.
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Affiliation(s)
- Jun Liu
- Tianjin Key Laboratory for Advanced Mechatronic System Design and Intelligent Control, National Demonstration Center for Experimental Mechanical and Electrical Engineering Education, Tianjin University of Technology, Tianjin, China (mainland)
| | - Lanlan Tian
- Tianjin Key Laboratory for Advanced Mechatronic System Design and Intelligent Control, National Demonstration Center for Experimental Mechanical and Electrical Engineering Education, Tianjin University of Technology, Tianjin, China (mainland)
| | - Songli Wang
- Tianjin Key Laboratory for Advanced Mechatronic System Design and Intelligent Control, National Demonstration Center for Experimental Mechanical and Electrical Engineering Education, Tianjin University of Technology, Tianjin, China (mainland)
| | - Zhiwei Luo
- Organization of Advanced Science and Technology, Kobe University, Kobe, Hyogo, Japan
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Cho SG, Jabin Z, Bom HHS. Safer stress tests for myocardial perfusion imaging. J Nucl Cardiol 2019; 26:629-632. [PMID: 29039085 DOI: 10.1007/s12350-017-1083-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, South Korea.
| | - Zeenat Jabin
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322, Seoyang-ro Hwasun-eup, Hwasun-gun, Jeonnam, 58128, South Korea
| | - Henry Hee-Seung Bom
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322, Seoyang-ro Hwasun-eup, Hwasun-gun, Jeonnam, 58128, South Korea
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Ischemic burden assessment of myocardial perfusion CT, compared with SPECT using semi-quantitative and quantitative approaches. Int J Cardiol 2019; 278:287-294. [DOI: 10.1016/j.ijcard.2018.12.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/28/2018] [Accepted: 12/13/2018] [Indexed: 01/14/2023]
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Abstract
PURPOSE OF REVIEW Purine nucleosides and nucleotides are released in the extracellular space following cell injury and act as paracrine mediators through a number of dedicated membrane receptors. In particular, extracellular ATP (eATP) significantly influences T-lymphocyte activation and phenotype. The purpose of this review is to discuss the role of ATP signaling in the T-cell-mediated alloimmune response. RECENT FINDINGS In various animal models of solid transplantation, the purinergic axis has been targeted to prevent acute rejection and to promote long-term graft tolerance. The inhibition of ATP-gated P2X receptors has been shown to halt lymphocyte activation, to downregulate both Th1 and Th17 responses and to promote T-regulatory (Treg) cell differentiation. Similarly, the inhibition of ATP signaling attenuated graft-versus-host disease in mice undergoing hematopoietic cell transplantation. Significantly, different drugs targeting the purinergic system have been recently approved for human use and may be a viable therapeutic option for transplant patients. SUMMARY The inhibition of eATP signaling downregulates the alloimmune response, expands Treg cells and promotes graft survival. This robust preclinical evidence and the recent advances in pharmacological research may lead to intriguing clinical applications.
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Pontone G, Andreini D, Guaricci AI, Baggiano A, Fazzari F, Guglielmo M, Muscogiuri G, Berzovini CM, Pasquini A, Mushtaq S, Conte E, Calligaris G, De Martini S, Ferrari C, Galli S, Grancini L, Ravagnani P, Teruzzi G, Trabattoni D, Fabbiocchi F, Lualdi A, Montorsi P, Rabbat MG, Bartorelli AL, Pepi M. Incremental Diagnostic Value of Stress Computed Tomography Myocardial Perfusion With Whole-Heart Coverage CT Scanner in Intermediate- to High-Risk Symptomatic Patients Suspected of Coronary Artery Disease. JACC Cardiovasc Imaging 2019; 12:338-349. [DOI: 10.1016/j.jcmg.2017.10.025] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/18/2017] [Accepted: 10/19/2017] [Indexed: 12/13/2022]
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Current Evidence in Cardiothoracic Imaging: Growing Evidence for Coronary Computed Tomography Angiography as a First-line Test in Stable Chest Pain. J Thorac Imaging 2019; 34:4-11. [DOI: 10.1097/rti.0000000000000357] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Diagnostic accuracy of simultaneous evaluation of coronary arteries and myocardial perfusion with single stress cardiac computed tomography acquisition compared to invasive coronary angiography plus invasive fractional flow reserve. Int J Cardiol 2018; 273:263-268. [DOI: 10.1016/j.ijcard.2018.09.065] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 09/16/2018] [Accepted: 09/19/2018] [Indexed: 11/18/2022]
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CT Myocardial Perfusion Imaging: A New Frontier in Cardiac Imaging. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7295460. [PMID: 30406139 PMCID: PMC6204157 DOI: 10.1155/2018/7295460] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/09/2018] [Indexed: 12/21/2022]
Abstract
The past two decades have witnessed rapid and remarkable technical improvement of multidetector computed tomography (CT) in both image quality and diagnostic accuracy. These improvements include higher temporal resolution, high-definition and wider detectors, the introduction of dual-source and dual-energy scanners, and advanced postprocessing. Current new generation multidetector row (≥64 slices) CT systems allow an accurate and reliable assessment of both coronary epicardial stenosis and myocardial CT perfusion (CTP) imaging at rest and during pharmacologic stress in the same examination. This novel application makes CT the unique noninvasive "one-stop-shop" method for a comprehensive assessment of both anatomical coronary atherosclerosis and its physiological consequences. Myocardial CTP imaging can be performed with different approaches such as static arterial first-pass imaging, and dynamic CTP imaging, with their own advantages and disadvantages. Static CTP can be performed using single-energy or dual-energy CT, employing qualitative or semiquantitative analysis. In addition, dynamic CTP can obtain quantitative data of myocardial blood flow and coronary flow reserve. The purpose of this review was to summarize all available evidence about the emerging role of myocardial CTP to identify ischemia-associated lesions, focusing on technical considerations, clinical applications, strengths, limitations, and the more promising future fields of interest in the broad spectra of ischemic heart disease.
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Yi Y, Wu W, Lin L, Zhang HZ, Qian H, Shen ZJ, Wang Y, Jin ZY, Litt H, Wang YN. Single-phase coronary artery CT angiography extracted from stress dynamic myocardial CT perfusion on third-generation dual-source CT: Validation by coronary angiography. Int J Cardiol 2018; 269:343-349. [DOI: 10.1016/j.ijcard.2018.06.112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/02/2018] [Accepted: 06/29/2018] [Indexed: 10/28/2022]
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Ramsey BC, Fentanes E, Choi AD, Branch KR, Thomas DM. Myocardial Assessment with Cardiac CT: Ischemic Heart Disease and Beyond. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018; 11:16. [PMID: 29963220 PMCID: PMC5984644 DOI: 10.1007/s12410-018-9456-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to highlight recent advancements, current trends, and the expanding role for cardiac CT (CCT) in the evaluation of ischemic heart disease, nonischemic cardiomyopathies, and some specific congenital myocardial disease states. RECENT FINDINGS CCT is a highly versatile imaging modality for the assessment of numerous cardiovascular disease states. Coronary CT angiography (CCTA) is now a well-established first-line imaging modality for the exclusion of significant coronary artery disease (CAD); however, CCTA has modest positive predictive value and specificity for diagnosing obstructive CAD in addition to limited capability to evaluate myocardial tissue characteristics. SUMMARY CTP, when combined with CCTA, presents the potential for full functional and anatomic assessment with a single modality. CCT is a useful adjunct in select patients to both TTE and CMR in the evaluation of ventricular volumes and systolic function. Newer applications, such as dynamic CTP and DECT, are promising diagnostic tools offering the possibility of more quantitative assessment of ischemia. The superior spatial resolution and volumetric acquisition of CCT has an important role in the diagnosis of other nonischemic causes of cardiomyopathies.
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Affiliation(s)
- Bryan C. Ramsey
- Cardiology Division, Department of Medicine, San Antonio Military Medical Center, San Antonio, TX USA
| | - Emilio Fentanes
- Cardiology Division, Department of Medicine, Tripler Army Medical Center, Honolulu, HI USA
| | - Andrew D. Choi
- Division of Cardiology, Department of Radiology, The George Washington University School of Medicine, Washington, DC USA
| | | | - Dustin M. Thomas
- Cardiology Division, Department of Medicine, San Antonio Military Medical Center, San Antonio, TX USA
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Diagnostic accuracy of semi-automatic quantitative metrics as an alternative to expert reading of CT myocardial perfusion in the CORE320 study. J Cardiovasc Comput Tomogr 2018; 12:212-219. [DOI: 10.1016/j.jcct.2018.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/16/2018] [Accepted: 03/31/2018] [Indexed: 11/17/2022]
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33
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von Spiczak J, Manka R, Mannil M, Oebel S, Hamada S, Higashigaito K, Klotz E, Ruschitzka F, Alkadhi H. 3D fusion of coronary CT angiography and CT myocardial perfusion imaging: Intuitive assessment of morphology and function. J Cardiovasc Comput Tomogr 2017; 11:437-443. [DOI: 10.1016/j.jcct.2017.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/04/2017] [Indexed: 10/18/2022]
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Branch KR, Haley RD, Bittencourt MS, Patel AR, Hulten E, Blankstein R. Myocardial computed tomography perfusion. Cardiovasc Diagn Ther 2017; 7:452-462. [PMID: 29255689 DOI: 10.21037/cdt.2017.06.11] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite having excellent diagnostic accuracy to detect anatomical coronary stenosis, coronary CT angiography (CTA) has a limited specificity to detect myocardial ischemia. CT perfusion (CTP) can identify myocardial perfusion defects during vasodilator stress, and when added to coronary CTA, improves the specificity of detecting hemodynamically significant stenosis. A CTP protocol typically involves the acquisition of two separate data sets: (I) a rest scan that can be used as both a coronary CTA and for evaluating rest myocardial perfusion, and (II) a stress CTP scan acquired during vasodilator stress testing. This review summarizes some the techniques, strengths, and limitations of CTP, and provides an overview of the recent evidence supporting the potential use of CTP in clinical practice.
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Affiliation(s)
- Kelley R Branch
- Department of Medicine (Cardiovascular Division), University of Washington, Seattle, WA, USA
| | - Ryan D Haley
- Cardiology Service, Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Marcio Sommer Bittencourt
- Division of Internal Medicine, University Hospital and State of São Paulo Cancer Institute (ICESP), University of São Paulo, São Paulo, Brazil.,Preventive Medicine Center Hospital Israelita Albert Einstein and School of Medicine, Faculdade Israelita de Ciência da Saúde Albert Einstein, São Paulo, Brazil
| | - Amit R Patel
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Edward Hulten
- Cardiology Service, Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Improved Discrimination of Myocardial Perfusion Defects at Low Energy Levels Using Virtual Monochromatic Imaging. J Comput Assist Tomogr 2017; 41:661-667. [PMID: 28296684 DOI: 10.1097/rct.0000000000000584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of this study was to explore the diagnostic performance of dual-energy computed tomography perfusion (DE-CTP) at different energy levels. METHODS Patients with known or suspected coronary artery disease underwent stress and rest DE-CTP and single-photon emission computed tomography. Images were evaluated using monochromatic data, and perfusion defects were initially identified in a qualitative manner and subsequently confirmed using attenuation levels. RESULTS Thirty-six patients were included. Sensitivity, specificity, positive predictive value, and negative predictive value of DE-CTP for the identification of perfusion defects were 84.1%, 94.2%, 77.3%, and 96.2%, respectively. Perfusion defects showed significantly lower attenuation than normal segments, with the largest differences among low energy levels (sensitivity of 96% and specificity of 98% using a cutoff value ≤ 153 Hounsfield units at 40 keV), progressively declining at the higher levels (P < 0.001). CONCLUSIONS Dual-energy CTP at the lowest energy levels allowed improved discrimination of perfusion defects compared with higher energy levels.
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Myocardial CT Perfusion: A Review of Current Modalities, Technology, and Clinical Performance. CURRENT CARDIOVASCULAR IMAGING REPORTS 2017. [DOI: 10.1007/s12410-017-9423-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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38
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van Rosendael AR, Dimitriu-Leen AC, de Graaf MA, van Zwet EW, Jukema JW, Bax JJ, Kroft LJ, Scholte AJ. Impact of computed tomography myocardial perfusion following computed tomography coronary angiography on downstream referral for invasive coronary angiography, revascularization and, outcome at 12 months. Eur Heart J Cardiovasc Imaging 2017; 18:969-977. [DOI: 10.1093/ehjci/jex055] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/06/2017] [Indexed: 02/02/2023] Open
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Benz DC, Mikulicic F, Gräni C, Moret D, Possner M, Clerc OF, Studer Bruengger AA, Gaemperli O, Buechel RR, Pazhenkottil AP, Kaufmann PA. Long-term outcome prediction by functional parameters derived from coronary computed tomography angiography. Int J Cardiol 2017; 243:533-537. [PMID: 28592383 DOI: 10.1016/j.ijcard.2017.05.083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/28/2017] [Accepted: 05/17/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Estimation of hemodynamic relevance of a coronary stenosis from coronary computed angiography (CCTA) has raised substantial interest. Recently, the corrected coronary opacification (CCO) decrease and the transluminal attenuation gradient (TAG) have been suggested as faster alternatives to the FFRCT. The aim of the study was to evaluate whether the diagnostic accuracy of CCO decrease and TAG translates into an added prognostic value in patients evaluated for coronary artery disease (CAD). METHODS This retrospective study consists of 162 consecutive patients referred for evaluation of known or suspected CAD by CCTA. CCO decrease was defined as difference of mean luminal coronary attenuation normalized to aorta attenuation proximal-distal of a stenosis. To calculate TAG, mean attenuation was measured at 5-mm intervals from the ostium to a distal segment with a minimal cross-sectional area of 2.0mm2. Death, myocardial infarction, unstable angina requiring hospitalization, and coronary revascularization were defined as major adverse cardiac events (MACE). Multivariate analysis included covariates age, sex, ≥3 cardiovascular risk factors and stenosis severity. RESULTS Follow-up was completed in 154 patients, CAD was found in 72. During median follow-up of 6.1years (interquartile range, 5.8-6.9years), 55 patients experienced a MACE. Among CAD patients, the presence of an abnormal CCO decrease (p<0.05) but not TAG (p=0.894) was associated with a worse MACE-free survival. In multivariate analysis, CCO decrease was an independent predictor of MACE (HR, 2.27; 95% CI, 1.14-4.52; p=0.02) while TAG was not predictive (p=0.895). CONCLUSION In CAD patients, CCO decrease adds long-term prognostic value over clinical characteristics and stenosis severity while TAG does not.
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Affiliation(s)
- Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Fran Mikulicic
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Dominic Moret
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Mathias Possner
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Olivier F Clerc
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Annina A Studer Bruengger
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Oliver Gaemperli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland.
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Rossi A, Wragg A, Klotz E, Pirro F, Moon JC, Nieman K, Pugliese F. Dynamic Computed Tomography Myocardial Perfusion Imaging: Comparison of Clinical Analysis Methods for the Detection of Vessel-Specific Ischemia. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005505. [PMID: 28389506 DOI: 10.1161/circimaging.116.005505] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 02/03/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The clinical analysis of myocardial dynamic computed tomography myocardial perfusion imaging lacks standardization. The objective of this prospective study was to compare different analysis approaches to diagnose ischemia in patients with stable angina referred for invasive coronary angiography. METHODS AND RESULTS Patients referred for evaluation of stable angina symptoms underwent adenosine-stress dynamic computed tomography myocardial perfusion imaging with a second-generation dual-source scanner. Quantitative perfusion parameters, such as blood flow, were calculated by parametric deconvolution for each myocardial voxel. Initially, perfusion parameters were extracted according to standard 17-segment model of the left ventricle (fully automatic analysis). These were then manually sampled by an operator (semiautomatic analysis). Areas under the receiver-operating characteristic curves of the 2 different approaches were compared. Invasive fractional flow reserve ≤0.80 or diameter stenosis ≥80% on quantitative coronary angiography was used as reference standard to define ischemia. We enrolled 115 patients (88 men; age 57±9 years). There were 72 of 286 (25%) vessels causing ischemia in 52 of 115 (45%) patients. The semiautomatic analysis method was better than the fully automatic method at predicting ischemia (areas under the receiver-operating characteristic curves, 0.87 versus 0.69; P<0.001) with readings obtained in the endocardial myocardium performing better than those in the epicardial myocardium (areas under the receiver-operating characteristic curves, 0.87 versus 0.72; P<0.001). The difference in performance between blood flow, expressed as relative to remote myocardium, and absolute blood flow was not statistically significant (areas under the receiver-operating characteristic curves, 0.90 versus 0.87; P=ns). CONCLUSIONS Endocardial perfusion parameters obtained by semiautomatic analysis of dynamic computed tomography myocardial perfusion imaging may permit robust discrimination between coronary vessels causing ischemia versus not causing ischemia.
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Affiliation(s)
- Alexia Rossi
- From the Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom and Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (A.R., A.W., F. Pirro, F. Pugliese); Siemens Healthineers, Forchheim, Germany (E.K.); Institute of Cardiovascular Science, University College London, United Kingdom (J.C.M.); and Departments of Cardiology and Radiology, Erasmus MC University Medical Centre Rotterdam, The Netherlands (K.N.)
| | - Andrew Wragg
- From the Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom and Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (A.R., A.W., F. Pirro, F. Pugliese); Siemens Healthineers, Forchheim, Germany (E.K.); Institute of Cardiovascular Science, University College London, United Kingdom (J.C.M.); and Departments of Cardiology and Radiology, Erasmus MC University Medical Centre Rotterdam, The Netherlands (K.N.)
| | - Ernst Klotz
- From the Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom and Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (A.R., A.W., F. Pirro, F. Pugliese); Siemens Healthineers, Forchheim, Germany (E.K.); Institute of Cardiovascular Science, University College London, United Kingdom (J.C.M.); and Departments of Cardiology and Radiology, Erasmus MC University Medical Centre Rotterdam, The Netherlands (K.N.)
| | - Federica Pirro
- From the Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom and Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (A.R., A.W., F. Pirro, F. Pugliese); Siemens Healthineers, Forchheim, Germany (E.K.); Institute of Cardiovascular Science, University College London, United Kingdom (J.C.M.); and Departments of Cardiology and Radiology, Erasmus MC University Medical Centre Rotterdam, The Netherlands (K.N.)
| | - James C Moon
- From the Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom and Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (A.R., A.W., F. Pirro, F. Pugliese); Siemens Healthineers, Forchheim, Germany (E.K.); Institute of Cardiovascular Science, University College London, United Kingdom (J.C.M.); and Departments of Cardiology and Radiology, Erasmus MC University Medical Centre Rotterdam, The Netherlands (K.N.)
| | - Koen Nieman
- From the Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom and Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (A.R., A.W., F. Pirro, F. Pugliese); Siemens Healthineers, Forchheim, Germany (E.K.); Institute of Cardiovascular Science, University College London, United Kingdom (J.C.M.); and Departments of Cardiology and Radiology, Erasmus MC University Medical Centre Rotterdam, The Netherlands (K.N.)
| | - Francesca Pugliese
- From the Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom and Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (A.R., A.W., F. Pirro, F. Pugliese); Siemens Healthineers, Forchheim, Germany (E.K.); Institute of Cardiovascular Science, University College London, United Kingdom (J.C.M.); and Departments of Cardiology and Radiology, Erasmus MC University Medical Centre Rotterdam, The Netherlands (K.N.).
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Abstract
Coronary computed tomography angiography (CCTA) plays an important role in many specific scenarios such as in symptomatic patients with intermediate pretest of coronary artery disease (CAD), as well as in the triage of patients with acute chest pain with TIMI risk ≤2. However, it cannot detect the presence of associated ischemia, which is critical for clinical decision making among patients with moderate to severe stenosis. Although functional information can be obtained with different non-invasive tools, cardiac CT is the unique modality that can perform a comprehensive evaluation of coronary anatomy plus the functional significance of lesions. Myocardial CT perfusion (CTP) can be performed with different approaches such as static and dynamic CTP. In addition, static CTP can be performed using single energy CT (SECT) or dual energy CT (DECT). In this review, we will discuss the technical parameters and the available clinical evidence of static CTP using both SECT and DECT.
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Affiliation(s)
- Patricia Carrascosa
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Buenos Aires, Argentina
| | - Carlos Capunay
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Buenos Aires, Argentina
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Cademartiri F, Seitun S, Clemente A, La Grutta L, Toia P, Runza G, Midiri M, Maffei E. Myocardial blood flow quantification for evaluation of coronary artery disease by computed tomography. Cardiovasc Diagn Ther 2017; 7:129-150. [PMID: 28540209 DOI: 10.21037/cdt.2017.03.22] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
During the last decade coronary computed tomography angiography (CTA) has become the preeminent non-invasive imaging modality to detect coronary artery disease (CAD) with high accuracy. However, CTA has a limited value in assessing the hemodynamic significance of a given stenosis due to a modest specificity and positive predictive value. In recent years, different CT techniques for detecting myocardial ischemia have emerged, such as CT-derived fractional flow reserve (FFR-CT), transluminal attenuation gradient (TAG), and myocardial CT perfusion (CTP) imaging. Myocardial CTP imaging can be performed with a single static scan during first pass of the contrast agent, with monoenergetic or dual-energy acquisition, or as a dynamic, time-resolved scan during stress by using coronary vasodilator agents (adenosine, dipyridamole, or regadenoson). A number of CTP techniques are available, which can assess myocardial perfusion in both a qualitative, semi-quantitative or quantitative manner. Once used primarily as research tools, these modalities are increasingly being used in routine clinical practice. All these techniques offer the substantial advantage of combining anatomical and functional evaluation of flow-limiting coronary stenosis in the same examination that would be beneficial for clinical decision-making. This review focuses on the state-of the-art and future trends of these evolving imaging modalities in the field of cardiology for the physiologic assessments of CAD.
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Affiliation(s)
- Filippo Cademartiri
- Department of Radiology, Montreal Heart Institute, Université de Montreal, Montreal, Canada.,Department of Radiology, Erasmus Medical Center University, Rotterdam, The Netherlands
| | - Sara Seitun
- Department of Radiology, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Alberto Clemente
- Department of Radiology, Fondazione Toscana Gabriele Monasterio, Pisa and Massa, Italy
| | | | - Patrizia Toia
- Department of Radiology, University of Palermo, Palermo, Italy
| | - Giuseppe Runza
- Department of Radiology, P.O. Umberto I, Azienda Sanitaria Provinciale 8, Siracusa, Italy
| | - Massimo Midiri
- Department of Radiology, University of Palermo, Palermo, Italy
| | - Erica Maffei
- Department of Radiology, Montreal Heart Institute, Université de Montreal, Montreal, Canada
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43
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CT myocardial perfusion imaging: current status and future perspectives. Int J Cardiovasc Imaging 2017; 33:1009-1020. [DOI: 10.1007/s10554-017-1102-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/24/2017] [Indexed: 12/24/2022]
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44
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André F, Buss SJ, Friedrich MG. The role of MRI and CT for diagnosis and work-up in suspected ACS. Diagnosis (Berl) 2016. [DOI: 10.1515/dx-2016-0029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
AbstractThis article describes the role of cardiovascular magnetic resonance (CMR) and cardiac computed tomography (CCT) in the diagnostic work-up of patients with suspected acute coronary syndrome (ACS). Recent studies on the principles, diagnostic targets, clinical utility, accuracy, prognostic relevance and implications for clinical decision-making are discussed and current state-of-the-art and novel approaches are presented. The authors recognize that in ACS, time is of the essence and therefore put a special emphasis on the feasibility of tomographic cardiac imaging in realistic clinical settings.
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Bischoff B, Deseive S, Rampp M, Todica A, Wermke M, Martinoff S, Massberg S, Reiser MF, Becker HC, Hausleiter J. Myocardial ischemia detection with single-phase CT perfusion in symptomatic patients using high-pitch helical image acquisition technique. Int J Cardiovasc Imaging 2016; 33:569-576. [PMID: 27848163 DOI: 10.1007/s10554-016-1020-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/11/2016] [Indexed: 12/14/2022]
Abstract
Coronary CT angiography (CCTA) suffers from a reduced diagnostic accuracy in patients with heavily calcified coronary arteries or prior myocardial revascularisation due to artefacts caused by calcifications and stent material. CT myocardial perfusion imaging (CTMPI) yields high potential for the detection of myocardial ischemia and might help to overcome the above mentioned limitations. We analysed CT single-phase perfusion using high-pitch helical image acquisition technique in patients with prior myocardial revascularisation. Thirty-six patients with an indication for invasive coronary angiography (28 with coronary stents, 2 with coronary artery bypass grafts and 6 with both) were included in this prospective study at two study sites. All patients were examined on a 2nd generation dual-source CT system. Stress CT images were obtained using a prospectively ECG-triggered single-phase high-pitch helical image acquisition technique. During stress the tracer for myocardial perfusion (MP) SPECT imaging was administered. Rest CT images were acquired using prospectively ECG-triggered sequential CT. MP-SPECT imaging and invasive coronary angiography served as standard of reference. In this heavily diseased patient cohort CCTA alone showed a low overall diagnostic accuracy for detection of hemodynamically relevant coronary artery stenosis of only 31% on a per-patient base and 60% on a per-vessel base. Combining CCTA and CTMPI allowed for a significantly higher overall diagnostic accuracy of 78% on a per-patient base and 92% on a per-vessel base (p < 0.001). Mean radiation dose for stress CT scans was 0.9 mSv, mean radiation dose for rest CT scans was 5.0 mSv. In symptomatic patients with known coronary artery disease and prior myocardial revascularization combining CCTA and CTMPI showed significantly higher diagnostic accuracy in detection of hemodynamically significant coronary artery stenosis when compared to CCTA alone.
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Affiliation(s)
- Bernhard Bischoff
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377, Munich, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany.
| | - Simon Deseive
- Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-University Hospital Munich, Munich, Germany
| | - Martin Rampp
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Andrei Todica
- Klinik und Poliklinik für Nuklearmedizin, Ludwig-Maximilians-University Hospital Munich, Munich, Germany
| | - Marc Wermke
- Institut für Radiologie und Nuklearmedizin, Deutsches Herzzentrum München, Klinik an der TU München, Munich, Germany
| | - Stefan Martinoff
- Institut für Radiologie und Nuklearmedizin, Deutsches Herzzentrum München, Klinik an der TU München, Munich, Germany
| | - Steffen Massberg
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-University Hospital Munich, Munich, Germany
| | - Maximilian F Reiser
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hans-Christoph Becker
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-University Hospital Munich, Munich, Germany
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46
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Gonçalves PDA, Rodríguez-Granillo GA, Spitzer E, Suwannasom P, Loewe C, Nieman K, Garcia-Garcia HM. Functional Evaluation of Coronary Disease by CT Angiography. JACC Cardiovasc Imaging 2016; 8:1322-35. [PMID: 26563862 DOI: 10.1016/j.jcmg.2015.09.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 08/30/2015] [Accepted: 09/03/2015] [Indexed: 12/24/2022]
Abstract
In recent years, several technical developments in the field of cardiac computed tomography (CT) have made possible the extraction of functional information from an anatomy-based examination. Several different lines have been explored and will be reviewed in the present paper, namely: 1) myocardial perfusion imaging; 2) transluminal attenuation gradients and corrected coronary opacification indexes; 3) fractional flow reserve computed from CT; and 4) extrapolation from atherosclerotic plaque characteristics. In view of these developments, cardiac CT has the potential to become in the near future a truly 2-in-1 noninvasive evaluation for coronary artery disease.
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Affiliation(s)
| | - Gastón A Rodríguez-Granillo
- Department of Cardiovascular Imaging, Diagnostico Maipu, and Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), Buenos Aires, Argentina
| | | | | | - Christian Loewe
- Section of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Koen Nieman
- Departments of Cardiology and Radiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hector M Garcia-Garcia
- Cardialysis B.V., Rotterdam, the Netherlands; Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.
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47
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Verändert die Koronar-CT den klinischen Alltag des Kardiologen? Herz 2016; 41:405-12. [DOI: 10.1007/s00059-016-4452-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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48
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CT myocardial perfusion imaging: current status and future directions. Clin Radiol 2016; 71:739-49. [DOI: 10.1016/j.crad.2016.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 01/15/2023]
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49
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Hecht HS, Narula J, Fearon WF. Fractional Flow Reserve and Coronary Computed Tomographic Angiography. Circ Res 2016; 119:300-16. [DOI: 10.1161/circresaha.116.307914] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/25/2016] [Indexed: 12/14/2022]
Abstract
Invasive fractional flow reserve (FFR) is now the gold standard for intervention. Noninvasive functional imaging analyses derived from coronary computed tomographic angiography (CTA) offer alternatives for evaluating lesion-specific ischemia. CT-FFR, CT myocardial perfusion imaging, and transluminal attenuation gradient/corrected contrast opacification have been studied using invasive FFR as the gold standard. CT-FFR has demonstrated significant improvement in specificity and positive predictive value compared with CTA alone for predicting FFR of ≤0.80, as well as decreasing the frequency of nonobstructive invasive coronary angiography. High-risk plaque characteristics have also been strongly implicated in abnormal FFR. Myocardial computed tomographic perfusion is an alternative method with promising results; it involves more radiation and contrast. Transluminal attenuation gradient/corrected contrast opacification is more controversial and may be more related to vessel diameter than stenosis. Important considerations remain: (1) improvement of CTA quality to decrease unevaluable studies, (2) is the diagnostic accuracy of CT-FFR sufficient? (3) can CT-FFR guide intervention without invasive FFR confirmation? (4) what are the long-term outcomes of CT-FFR–guided treatment and how do they compare with other functional imaging-guided paradigms? (5) what degree of stenosis on CTA warrants CT-FFR? (6) how should high-risk plaque be incorporated into treatment decisions? (7) how will CT-FFR influence other functional imaging test utilization, and what will be the effect on the practice of cardiology? (8) will a workstation-based CT-FFR be mandatory? Rapid progress to date suggests that CTA-based lesion-specific ischemia will be the gatekeeper to the cardiac catheterization laboratory and will transform the world of intervention.
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Affiliation(s)
- Harvey S. Hecht
- From the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); Department of Cardiology, Stanford University School of Medicine, CA (W.F.F.)
| | - Jagat Narula
- From the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); Department of Cardiology, Stanford University School of Medicine, CA (W.F.F.)
| | - William F. Fearon
- From the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); Department of Cardiology, Stanford University School of Medicine, CA (W.F.F.)
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50
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Williams MC, Mirsadraee S, Dweck MR, Weir NW, Fletcher A, Lucatelli C, MacGillivray T, Golay SK, Cruden NL, Henriksen PA, Uren N, McKillop G, Lima JAC, Reid JH, van Beek EJR, Patel D, Newby DE. Computed tomography myocardial perfusion vs 15O-water positron emission tomography and fractional flow reserve. Eur Radiol 2016; 27:1114-1124. [PMID: 27334015 PMCID: PMC5306314 DOI: 10.1007/s00330-016-4404-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 05/05/2016] [Accepted: 05/12/2016] [Indexed: 11/25/2022]
Abstract
Objectives Computed tomography (CT) can perform comprehensive cardiac imaging. We compared CT coronary angiography (CTCA) and CT myocardial perfusion (CTP) with 15O-water positron emission tomography (PET) and invasive coronary angiography (ICA) with fractional flow reserve (FFR). Methods 51 patients (63 (61–65) years, 80 % male) with known/suspected coronary artery disease (CAD) underwent 320-multidetector CTCA followed by “snapshot” adenosine stress CTP. Of these 22 underwent PET and 47 ICA/FFR. Obstructive CAD was defined as CTCA stenosis >50 % and CTP hypoperfusion, ICA stenosis >70 % or FFR <0.80. Results PET hyperaemic myocardial blood flow (MBF) was lower in obstructive than non-obstructive territories defined by ICA/FFR (1.76 (1.32–2.20) vs 3.11 (2.44–3.79) mL/(g/min), P < 0.001) and CTCA/CTP (1.76 (1.32–2.20) vs 3.12 (2.44–3.79) mL/(g/min), P < 0.001). Baseline and hyperaemic CT attenuation density was lower in obstructive than non-obstructive territories (73 (71–76) vs 86 (84–88) HU, P < 0.001 and 101 (96–106) vs 111 (107–114) HU, P 0.001). PET hyperaemic MBF corrected for rate pressure product correlated with CT attenuation density (r = 0.579, P < 0.001). There was excellent per-patient sensitivity (96 %), specificity (85 %), negative predictive value (90 %) and positive predictive value (94 %) for CTCA/CTP vs ICA/FFR. Conclusion CT myocardial attenuation density correlates with 15O-water PET MBF. CTCA and CTP can accurately identify obstructive CAD. Key Points •CT myocardial perfusion can aid the assessment of suspected coronary artery disease. • CT attenuation density from “snapshot” imaging is a marker of myocardial perfusion. • CT myocardial attenuation density correlates with15O-water PET myocardial blood flow. • CT attenuation density is lower in obstructive territories defined by invasive angiography. • Diagnostic accuracy of CTCA+CTP is comparable to invasive angiography + fractional flow reserve. Electronic supplementary material The online version of this article (doi:10.1007/s00330-016-4404-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor's Building, 49 Little France Crescent, Edinburgh, UK, EH16 4SB.
| | - Saeed Mirsadraee
- Clinical Research Imaging Centre, University of Edinburgh, Edinburgh, UK
| | - Marc R Dweck
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor's Building, 49 Little France Crescent, Edinburgh, UK, EH16 4SB
| | - Nicholas W Weir
- Clinical Research Imaging Centre, University of Edinburgh, Edinburgh, UK
| | - Alison Fletcher
- Clinical Research Imaging Centre, University of Edinburgh, Edinburgh, UK
| | | | - Tom MacGillivray
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor's Building, 49 Little France Crescent, Edinburgh, UK, EH16 4SB
- Clinical Research Imaging Centre, University of Edinburgh, Edinburgh, UK
| | - Saroj K Golay
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor's Building, 49 Little France Crescent, Edinburgh, UK, EH16 4SB
| | | | | | - Neal Uren
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Graham McKillop
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - João A C Lima
- Departments of Medicine and Radiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - John H Reid
- Clinical Research Imaging Centre, University of Edinburgh, Edinburgh, UK
| | - Edwin J R van Beek
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor's Building, 49 Little France Crescent, Edinburgh, UK, EH16 4SB
- Clinical Research Imaging Centre, University of Edinburgh, Edinburgh, UK
| | - Dilip Patel
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David E Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor's Building, 49 Little France Crescent, Edinburgh, UK, EH16 4SB
- Clinical Research Imaging Centre, University of Edinburgh, Edinburgh, UK
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